What Happens If Medicare Part D Provisions Expire?

For more than a decade, the Medicare prescription drug program known as Medicare Part D has helped seniors and people with disabilities access the prescription drug coverage they need.

However, in 2019, provisions put into place by Congress that were designed to help keep costs down are set to expire. These provisions limited the annual increase in out-of-pocket costs that you are required to meet before getting access to a medicine. Without these protective measures in place, the amount that would have to be paid out-of-pocket for a prescription could spike significantly. So what can be done to help protect seniors from these potential increases?

Here’s what you need to know & how you can help:

What is Medicare Part D?

Medicare Part D provides drug coverage for seniors and people with disabilities. The design of the benefit includes a deductible, then the initial coverage phase where a person pays a co-payment or co-insurance for their medicines, followed by a coverage gap (also known as the “donut hole”), and finally catastrophic coverage. Once an individual has spent $5,000 out-of-pocket in 2018 ($5,100 in 2019), they are out of the coverage gap and automatically get catastrophic coverage, where they only pay 5% of the cost of the drug for the rest of the year.

What is the Issue?

Each year, the qualifying threshold for catastrophic coverage increases, but in 2010, Congress enacted provisions to slow the rate of increase and keep costs from rising too fast. This affordability measure is now at risk, as these provisions are set to expire at the end of 2019.

What Will Happen if These Affordability Provisions Expire?

If the Medicare Part D provisions expire in 2019, costs may increase significantly for many Medicare beneficiaries. The maximum out-of-pocket costs will grow from $5,100 in 2019 to $6,350 in 2020 – an increase of more than $1,200 in out-of-pocket costs patients will have to pay for prescription drugs before qualifying for catastrophic coverage.

What Can I Do?

While these affordability measures are currently at risk, it’s not too late to take action. You can help by urging elected officials to vote to pass legislation that would prevent a spike in out-of-pocket spending requirements in Medicare Part D.

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The health information contained herein is provided for educational purposes only and is not intended to replace discussions with a health care provider. All decisions regarding patient care should be made with a health care provider.